Updated: 2/19/2020

Testicular Tumors

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https://upload.medbullets.com/topic/116050/images/seminoma_of_the_testis.jpg
Introduction
  • Testicular tumors can be of germ cell or non-germ cell origin
    • germ cell origin
      • are the majority (95%) and are more commonly malignant
    • non-germ cell origin
      • usually benign
  • Epidemiology
    • incidence
      • most common cancer in men between 15-35 years
    • risk factors
      • cryptorchidism
      • Klinefelter syndrome
      • testicular feminization
Classification
  • Germ cell types
    • seminoma
      • malignant
      • most common testicular tumor
      • mostly affecting males 15-35 years
      • commonly metastasizes to para-aortic lymph nodes before hematogenous spread
    • embryonal carcinoma
      • malignant
      • commonly metastasizes early
    • yolk sac (endodermal sinus) tumor
      • seen in children < 4 years
    • choriocarcinoma
      • malignant
    • teratoma
      • mature teratoma in males is most often malignant
        • unlike females
  • Non-germ cell types
    • Leydig cell (sex-cord stromal)
    • Sertoli cell (sex-cord stromal)
    • Testicular lymphoma
      • most common testicular cancer in older men
      • involves both testes
Presentation
  • Symptoms
    • painless unilateral enlargement of testes
    • seminoma
      • homogenous testicular enlargement
    • embryonal carcinoma
      • painful
    • choriocarcinoma
      • gynecomastia
        • due to hCG production which is an LH analogue
    • Leydig cell
      • usually androgen producing
        • gynecomastia in men
        • precocious puberty in boys
  • Physical exam
    • solid mass of the testes is always cancer
Evaluation
  • Histology
    • seminoma
      • large cells in lobules with watery cytoplasm  
      • "fried egg" 
        • analogous to dysgerminoma of the ovary
    • embryonal carcinoma
      • glandular/papillary
    • yolk sac (endodermal sinus) tumor
      • yellow, mucinous
      • Schiller-Duval bodies resemble primitive glomeruli
    • choriocarcinoma
      • disordered syncytiotrophoblastic and cytotrophoblastic elements
    • teratoma
      • contain three tissue types
    • leydig cell
      • contains Reinke crystals
      • golden brown color
  • Serology
    • LDH
      • non-specific
    • specific tumor markers
      • embryonal carcinoma
        • ↑ AFP and hCG
      • yolk sac (endodermal sinus) tumor
        • ↑ AFP
      • choriocarcinoma
        • ↑ hCG
Treatment
  • Pharmacologic & radiation
    • radiation therapy
      • indications
        • seminoma is radiosensitive
  • Surgical
    • orchiectomy 
Prognosis
  • Seminoma
    • late metastasis and excellent prognosis
  • Embryonal
    • worse prognosis than seminoma
  • Choriocarcinoma
    • worst prognosis
      • in contrast to good prognosis in females
      • metastasizes to lungs

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(M1.ON.14.57) A 45-year-old man presents to his primary care provider for his yearly physical. On exam, the physician discovers a hard, testicular mass on the right testis. On further questioning, the patient remarks that he first noticed it 6 months ago, but did not think he needed to have it examined since it wasn't painful. Transillumination of the scrotum does not reveal translucency. The ultrasound of his right testis is shown in Figure A. Blood work reveals normal AFP and Beta-hCG. Chest radiograph and CT scan do not show positive lymph nodes or distant metastases. Which of the following is the most appropriate next step? Tested Concept

QID: 106375
FIGURES:
1

Biopsy

47%

(8/17)

2

Radical orchiectomy

41%

(7/17)

3

Chemotherapy

6%

(1/17)

4

Three month re-imaging

6%

(1/17)

5

No further workup, instruct patient to return if symptomatic

0%

(0/17)

M 3 E

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